Triage for Practice Nurses

Triage for PracticeNurses“Why didn’t they just go to thehospital, don’t they know they’resick?”

What is TRIAGE?• A French noun derived from the verbtrier, which means to sift or sort.• Has contemporary usage inagriculture, mining and the railways,and was imported into the Englishlanguage in the 18 th century todescribe the sorting of wool andcoffee.

Triage• In medicine, triage literally means thesorting of patients, on the basis oftheir illness and other factors, intocategories that determine the urgencyand extent if medical care required.

The Australasian NationalTriage Scale (NTS)

Triage for GeneralPractice• Telephone Triage• Face to face- make appointment- see urgently that day – what isurgent ?- get Doctor now to see pt- ring an ambulance and start first aid

Chest Pain• Difficult to differentiatebetween cardiac andnon-cardiac origin• Don’t be distracted byrepeat attendees,histrionics, other familymembers or “hangerson”• Focus on the patient atpresentation

Chest Pain AssessmentTriage Assessment• ABC• Skin colour, cyanosis, pallor• Respiratory status, quality ofrespiration, unusual chest movement• Any other obvious problems• General appearance, age

Chest Pain AssessmentThe simple mnemonic PQRSToffers a reliable approach tothe assessment of chest painof any origin

Chest Pain AssessmentQ – Quality• What does it feel like?• Ask to describe in own words what thediscomfort is like ( sharp, stabbing,burning, crushing).• Does any thing change the pain? –deep inspiration, cough andmovement

Chest Pain AssessmentR - Radiation / Region• Where is it located?• Does it go any where else?• Ask the patient to point to where thepain is at its worst

Chest Pain AssessmentS – Severity• How bad is the current condition?• Severity of an individual’s condition isdifficult to assess and is highly subjective• Ask patient to rate any pain sensation on ascale of 1 to 10• If patient has had ischaemic pain before,determine if it is greater or lesser severitythan usual

Chest Pain AssessmentT – Time / Onset/ Duration• Do you have any discomfort now?• When did this episode of pain start?• How long did it last?• Is it constant or does it come and go?• Did it come on suddenly or graduallyover a period of time?

Chest Pain AssessmentHistory taking MUSTNOT delayinterventions ordefinitive care

Chest Pain Assessment• Associated symptoms- nausea and vomiting- shortness of breath- diaphoresis- cough, productive or non-productive- fever- racing heart, palpitations

Chest Pain Assessment• Measures taken to relieve pain at rest- Anginine- GTN sprays- antacids- oxygen

Chest Pain Assessment• Past Medical History- previous myocardial infarction,cardiac surgery, angina- medications in particular: Digoxin,diuretics, beta blockers, ACE inhibitors- risk factors*smoking*hypertension*diabetes*+ve family history*obesity* hyperlipidaemia• Recent stress, illness or exertion

Differential Diagnosis –CardiovascularChest Pain- Typical angina- Prinzmetal or variant angina- Unstable or accelerating angina- Acute myocardial infarction- Aortic dissection- Mitral valve prolapse- Pericarditis- Dressler’s Syndrome

Differential Diagnosis –PulmonaryChest Pain- Pleuritic chest pain- Pneumonia- Pulmonary embolism- Pulmonary hypertension- Spontaneous pneumothorax

Differential Diagnosis –Gastrointestinal- Reflux oesophagitis- Oesophageal spasm- Peptic ulcer- Pancreatitis- Cholecystitis- CholelithiasisChest Pain

Differential Diagnosis –Chest PainMusculoskeletal disorders- Costochondritis- Tietze’s Syndrome- Rib fracture or trauma- Cancer metastasis- Sternoclavicular arthritis- Painful xiphoid syndrome- Fibromyalgia- Traumatic muscle pain- Shoulder arthritis/bursitis- Cervicothoracic nerve root compression

Differential Diagnosis –Miscellaneous- Herpes zoster- Anxiety/depressive disorder- Panic disorderChest Pain

Telephone Triage• Telephone Triage is the practice ofconducting a verbal interview toassess a patient’s health status and tooffer recommendations for treatmentand referral

Telephone Triage• The goal of Telephone Triage isappropriate patient referral to theappropriate level of care within anappropriate period of time

Telephone Triage• It is helpful to those calling, however:• It may be time consuming and it isoften difficult to determine the needsof the person calling for advice.• The nurse may be asked to make adiagnosis or to provide an opinion ofwhat she thinks may be wrong.

Telephone Triage• There are legal implications if an opinion isoffered which is incorrect, and nurses areable to be held liable for the informationgiven.• Other risks associated with telephone triageare offering the wrong advice, incorrectassessment, incomplete collection of data,caller mistrust or misunderstanding andpoor documentation

Telephone Triage• Remember – You are not making a“diagnosis” over the phone. Decisionsare made on acuity of signs andsymptoms.

Telephone TriageThe process of telephone triage has 5 maincomponents:• Introduction of self and openingcommunication channels• Performing the assessment via interview• Making the triage decision• Offer advice according to protocol orestablished guideline for care incorporatingfollow up plans• Document the call.

Telephone TriageStep 1: Introduce self and opencommunication• Give your name and title – so that yourpatient feels he/she is getting informationfrom a knowledgeable person, allowing fortrust and openness• Caring attitude – non judgemental manner,thus improving the amount and detail ofinformation revealed

Telephone TriageStep 2: Perform the interview• Establish if the call is an emergency to lifeor limb by the use of five questions.- symptoms- age- sex- breathing sounds- level of consciousness

Telephone TriageStep 2: cont.• Listen for non verbal cues – sentencestructure pauses, breathing patterns, cryingetc. Background noise may indicate furtherwhat pressures the caller is under.• If not talking to the patient, bringing themto the phone to listen to breathing,coughing etc will help

Telephone TriageStep 2: cont• Remember – the greater the amount ofinformation collected the more accurate ournursing diagnosis will be• Use open ended questions – try not to leadthe caller• Ask the person to describe his/hersymptoms, not to diagnose the cause of thesymptoms.

Telephone TriageStep 3: Making a triage decision.• Nursing diagnosis: establishespriorities of care based on thepatient’s signs and symptoms• Medical diagnosis: establishes thecause of the patient’s signs andsymptoms. Do not attempt to providea medical diagnosis.

Telephone TriageStep 3: cont• Use of protocols and guidelines will helpmake sure you do not miss information andhelps you make decisions more quickly• How well steps one and two are done willdetermine how well we do this step; keepthis in mind when gathering data, so it is inan organised fashion.

Telephone TriageStep 4: Offer advice• Based on acuity of the signs and symptoms• Disposition of the call may include- calling an ambulance- observe at home- see GP when convenient- transfer call to GP or other health careprovider, as appropriate- self treatment at home

Telephone TriageStep 4: cont• Ensure that the caller clearly understands theadvice by having the caller repeat the informationback to you• Encourage caller to call back if the conditionworsens, or if they have a further issue• In all cases – caller should be advised to go to theemergency department or attend their own doctorif there was no improvement in their condition, iftheir condition worsened or if they are still worried

Telephone TriageStep 5: Document the call• Be precise• Reflect advice given by the protocolfollowed• Include all data and as muchinformation as possible to give acomplete patient scenario

Telephone Triage - Tips• Avoid stereotypingcallers or problems• Avoid second guessingthe caller• Do not try to be anexpert on everything• Avoid absorbingpatient/caller anxiety• Make a nursingdiagnosis, not amedical diagnosis

Respiratory Distress –Asthma AssessmentVisual Assessment:• Skin colour: pallor, cyanosis• Level of consciousness• Respiratory status- ability to speak- ability to cough- ability to move air• Chest shape and movement

Respiratory DistressAssessment - AsthmaSubjective Assessment• History of present episode – Treat while assessing- how long have the current symptoms beenpresent? What were you doing when theyoccurred?- precipitating factors such as exposure to toxins,allergies, anxiety, URTI- is the patient becoming fatigued ?- reason for acute exacerbation?

Respiratory DistressAssessment - AsthmaSubjective Assessment cont.• Associated symptoms- cough (describe any sputum)- wheezing- chest pain- pleuritic: : sharp pain on inspiration- cardiac: crushing central chest pain- presence of orthopnoea or paroxysmal nocturnal dyspneoa –usually indicates cardiac origin- fever, chills- ankle oedema- voice changes- degree of anxiety

Respiratory DistressAssessment - AsthmaSubjective Assessment cont.• Measures taken to relieve symptoms, such as aspirin, nebuliser,medications• Past medical history- lung or cardiac disease- usual level of activity- history of smoking- medication including PRN meds- allergies – history of hay fever/asthma- hospitalisations, especially for respiratory disease- any other previous illness- trauma history- family history of asthma and allergies• Recent stress, emotional event or illness – Beware of oversimplifyingdiagnosis!!

Respiratory DistressAssessment - AsthmaObjective Assessment• Vital signs- respiratory rate: greater than 18-20 min or25-60 in children. Check rate, rhythm andquality of respirations. Note also accessorymuscle use and intercostal and sternalretractions- pulse: tachycardia (bradycardia withchildren) may indicate hypoxia

Respiratory DistressAssessment - Asthma• Vital signs cont.-blood pressure: note pulsusparadoxus- temperature: may need rectal tempif respiratory rate increased- peak flows: if patient distressedleave until later

Respiratory DistressAssessment - AsthmaObjective Assessment• Respiratory Effort- skin colour: cyanosis or pallor of lips ornail beds. Note diaphoresis- breathing pattern such as prolongedexpiratory phase, use of accessory muscles- stridor or audible wheeze- tracheal deviation- increased AP diameter (‘barrel chest’)- distended neck veins

Respiratory DistressAssessment - AsthmaObjective Assessment• Breath sounds- bilateral comparisons- presence or absence of crackles,wheezes- palpation: note crepitus

Respiratory DistressAssessment - AsthmaObjective assessment• Neurological status may be diminishedbecause of hypoxia; look for signs ofchange, such as lethargy, agitation,increased anxiety, confusion orirritability• Signs of external trauma

Adult Asthma Severity• MILD ATTACK- Respirations

Adult Asthma Severity• SEVERE ATTACK- Respirations > 25 per min- Heart rate > 120 bpm- Peak flow

Adult Asthma Severity• LIFE THREATENING- Decreased level of consciousness- Inability to speak- Cyanosis of lips/mouth- Bradycardia

Paediatric AsthmaWheeze Score (WS)0 = no wheeze1 = wheeze on terminal expiration heardwith a stethoscope2 = wheeze heard on inspiration andexpiration3 = wheeze heard without stethoscope,or ‘silent chest’

Paediatric AsthmaAccessory Muscle Score (AMS)0 = no accessory muscle usage1 = subtle but definite use of accessorymuscles2 = obvious use of accessory muscles3 = maximal use of accessory muscles

Paediatric AsthmaSeverityMild- Child who is not distressed- WS = 0,1- AMS = 0 or 1- o2sat = >95% in air

Paediatric AsthmaSeverityModerate- a distressed child with obviouswheeze, tachypnoea, tachycardia- WS = 2 or 3- AMS = 2- o2sat = 91%-95%95%

Paediatric AsthmaSeveritySevere- Marked distress, tachycardia,tachypnoea, marked reduction involume of breath sounds- WS = 3- AMS = 3- o2sat = < 90%

Headache

Headache• Most headaches seen in general practice aresimple or an associated symptom of thepatient's problem. However, we need to bevigilant for headaches that are clues todangerous problems because althoughheadache is a nearly universal part of thehuman experience, it is unusual for "theaverage person" to go to the GP with an"ordinary" headache.

Headache• Doing so (with the cost, inconvenience, anddiscomfort of a GP visit) should be a marker forconcern. The reason the patient comes will bebecause of what seems unusual or frustrating: i.e.,-"I never have a headache"or "worst headache of my life",- persistence ("It just won't go away"),- associated symptoms or interference withactivities of daily living (nausea/vomiting, fever, "Ican't sleep"),- or fears of worse possibilities ("we thought shemight be having a stroke").

HeadacheA good mnemonic would be PQRST:• P: : Provocative-Palliative Palliative factors; "what makes it worse orbetter?"• Q: : Qualitative: "Is it sharp, dull, aching, stabbing, burning,etc.?• R: : Radiation-Regional: Regional: "Where does your headache sit?,"does it go anywhere else?" e.g., , hemicranial, sinus pressureor tenderness, jaw or ear pain.• S: : Severity: "How bad does it feel?" 0-100scale, or "faces"scale, "has it kept you from working?"• T: : Temporal factors: "When did it start?", "Was it sudden orgradual?" Is it always the same, goes away for a whileentirely, or always there but gets worse in waves?" Is there apattern or association to the occurrence? e.g., , recurringwaking headache of brain tumour, or activity relatedexposures to toxins.

Headache• Questions regarding PMH may elicithypertension, cancer which may bemetastatic, TIAs, URTI or allergy symptoms,sinus or cranial surgery, ventriculo-peritoneal shunting of CSF fromhydrocephalus. Occupation may suggest atoxin, environmental problems, or exposureto pathogens (childcare worker, or foreigntravel). Habits such as alcohol orintravenous drug abuse which increase risk.

Headache• Neurologic signs and symptoms such aslethargy, any loss of consciousness,disorientation or confusion, dysarthria,visual changes such as photophobia,blurring, diplopia, halos around lights,speckles or jagged streaks, ataxia or gaitdisturbance, clumsy use of extremities,nausea or vomiting may be significant andshould be repeatedly sought. These shouldhave high priority.

General Practice Triage Protocols

General Practice Triage